This extract from Authenticity: Reclaiming Reality in a Counterfeit Culture by Alice Sherwood explores a tragic effect of information asymmetry.

Malaria. Its epithet: the “unsurpassed scourge of humankind” is well earned –  by some counts, more than half of all the people ever born have died of it. This highly infectious disease is killing the weak and vulnerable quickly, others more slowly. Even now, over 200m  people contract malaria every year, and around 500,000 of them die. Over 90% of them live in Africa, and most victims are children under the age of five.

The good news is that a cure has been discovered in China. The bad news is that counterfeiters have moved in and are selling fake versions of the cure, and desperate sufferers are buying them.

Many of us experienced the fear and misery of coronavirus, far fewer of us have come face to face with malaria.

From the outside you can’t tell the fake pharmaceuticals from the real. Same boxes, same blister packs, same capsules. But inside, the cure is diluted with so much mineral dust that you might as well chew on chalk for all the good it will do you. Some of the falsified pharmaceuticals do contain just a few grains of the real medicine. It’s not enough to cure anyone, but it is enough to allow a new mutant strain of the disease to develop. A strain for which there is no cure.

Many of us experienced the fear and misery of coronavirus, far fewer of us have come face to face with malaria. Organisations fighting the disease, from the World Health Organisation to the Gates Foundation, believe that with one final push we could consign malaria to medical history. But they face a number of enemies. Not only the malaria-bearing parasites hosted by mosquitoes, but also human parasites: those suppliers of counterfeit medicines to malaria sufferers, who know that in the absence of proper drugs, they are likely to die. Like all parasitism, it’s an asymmetric transaction: one where the parasites get the benefit, and their victims – pay the price.

Some 30% of anti-malarials sold in sub-Saharan Africa, and up to 50% in South East Asia, are fake or substandard. If those counterfeit drugs contained no active ingredients at all, then giving them to patients would be of no use to the patients, but would not harm others. But that is not the case. Very often, counterfeit drugs contain a tiny amount of the active ingredients of the genuine drugs that they imitate. And that causes harm that threatens us all.

Inside the body of a dying child, as counterfeit antimalarials encounter the parasites that carry the disease, a microscopic eugenics exercise is playing out. The less-than-lethal dose of active ingredient that the fake drug contains is too little to kill off all the parasites in the child’s bloodstream; the more robust ones will survive and reproduce so they make up a larger proportion of the population. The next time a mosquito feeds on the child’s blood, the tougher strain of parasite will be transmitted back into the mosquito population, and from there to new human hosts. As this cycle repeats hundreds and thousands of times, an  increasingly drug-resistant parasite population begins to emerge.

In South East Asia, where counterfeit anti-malarials have circulated for years, drug-resistant strains have been identified in several countries. Experts know that unless they can wipe out the mosquitoes that carry these new strains, they will likely spread to neighbouring countries – and then we could all be only a plane journey away from worldwide transmission (See box, A wider problem).

A Wider Problem
Counterfeit anti-malarials are just part of a much wider problem. WHO research suggests that every year up to a million people across the world, including 250,000 children, die as the result of falsified and substandard medicines. From the ‘life-saving cancer drug’ that is anything but – as happened in 2012, when cancer patients in California received vials of ‘Avastin’ that contained no active ingredients – to the counterfeit antibiotics that are estimated to have caused more than 8,000 people to whom they were given to prevent post-surgery infection to die over a five-year period in one Himalayan hospital. Counterfeit medicines are uniquely evil: they pretend to cure, but frequently kill. At best they are useless; at worst deadly.

The majority of the world’s Bad Pharma comes from China.

The majority of the world’s Bad Pharma comes from China. In part this is the result of haphazard regulation. China monitors pharmaceutical producers but not the intermediate chemical companies that manufacture many of the ingredients, making it easy for impure ingredients to find their way into the medicines. But the real issue is that corruption and deceit infect every stage of the supply chain.

Package designs are easy to counterfeit and pills can be bulked out with cheaper ingredients and sold to customers who, without laboratory or testing equipment, are powerless to tell whether what they are being given is a dud, or even deadly. There can be little doubt that the Chinese state is aware of the extent of the counterfeiting that is happening on its territory. Many of the companies selling fake pharma are owned or empowered by the state.

Up to 80% of drug trials are rigged or falsified and the academic institutions that conduct them are government-run. If we lose the race to eradicate malaria, much of the blame will lie at China’s door.

So it is a doleful irony that the anti-malarial drug, artemisinin – our current best line of defence against the disease – was discovered by the very nation whose counterfeits now threaten its eradication.

The story of the discovery of artemisinin is an extraordinary tribute to China’s ability to mobilise and organise when it has reason to do so. The earliest treatment for malaria,  discovered by explorers in the mid-seventeenth century, was quinine, extracted from the bark of the South American cinchona tree. By the twentieth century, quinine had given way to synthetic chloroquine. But the malaria-bearing parasites acquired resistance to chloroquine, and when a particularly severe outbreak of the disease coincided with the war in Vietnam, the battle against malaria acquired a new urgency.

Like the North Vietnamese Army,  the Viet Cong in the south were losing more troops to malaria than were dying in battle. Somewhere between 50% and 90% of their soldiers were so sick from the disease as to be useless. The Viet Cong pleaded with their principal supporter, China, to find a cure. In 1967, the Chinese set up a secret project to find a new drug to cure malaria.

A young scientist named Tu Youyou was appointed to lead the project. At first her team investigated modern synthetic compounds, but when several thousand existing drugs had been screened to no avail, they turned to an exploration of the traditional and folkloric remedies of so-called Traditional Chinese Medicine (see box, Mao’s medicine).

Mao's medicine
Traditional Chinese Medicine was very largely the creation of Mao Zedong. Some years earlier, faced with a shortage of doctors trained in Western evidence-based medicine, Mao had yoked together a thousand years or more of folk medicine, fairy tales, quackery, and herbal remedies under the banner of Traditional Chinese Medicine; decreed it to be on a par with Western medicine; and directed that the promotion of Chinese medicine should be made a priority.

Mao knew that most of this “medicine” didn’t work;  he confided in his own physician, he never touched the stuff himself. But Traditional Chinese Medicine led to China’s greatest medical discovery in artemisinin.

After examining over 2,000 herbs without success, Tu Youyou and her team alighted on one, known as sweet wormwood (Artemisia annua L.) According to the story, the breakthrough came when they uncovered a recipe in a physician’s handbook written in 340 CE that used artemisia plants (Qinghao) in the treatment of malaria.

For the best part of a decade Mao’s obsessively secretive China kept this important discovery to itself.

This was the great leap forward they needed. When extracted from the plant at low temperature, substances called artemisinins proved extremely potent against malaria-bearing parasites. This collection of derivatives is collectively referred to as artemisinin.

For the best part of a decade Mao’s obsessively-secretive China kept this important discovery to itself. Then, as Chinese scientific journals began to be translated into English in the early 1980s, the world started to pay attention. Soon Big Pharma was marketing various derivatives of artemisinin globally as a cure for malaria. A wartime emergency had spawned a peacetime miracle.

The ancient Chinese remedy had become the medical marvel that would save millions. Tu Youyou, awarded the Nobel Prize for medicine in 2015, described artemisinin as “a gift from Chinese Traditional Medicine to the world”. But what China gave with one hand it is now taking away with the other. The nation that discovered the cure for malaria is now allowing – even encouraging – it to be counterfeited.

When it comes to malaria, China is the solution and the problem. The country that seeks to become the most economically powerful nation in the world must also make the choice whether to cure or to kill.

Alice Sherwood

Alice is the author of the award-winning Authenticity: Reclaiming Reality in a Counterfeit Culture (HarperCollins 2022), which argues that although our counterfeit culture is shaped by the most powerful forces of evolution, …

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